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So, Fidel Castro is dead

Posted by on November 26, 2016 Comments Off on So, Fidel Castro is dead

As one wag on twitter said, everyone’s opinion will differ with everyone else’s opinion. We see video of Cuban exiles celebrating in Miami, while Havana is somber. Some thoughts:
castro
As one wag on twitter said, everyone’s opinion will differ with everyone else’s opinion. We see video of Cuban exiles celebrating in Miami, while Havana is somber. Some thoughts:
1. While Cubans are very racially mixed, the people in the streets of Miami are generally descendants of the Spanish conquerors, while those who supported Castro were generally descendants of African slaves.
2. Before Castro’s revolution, the Spanish Cubans were on top of the economy and political system, and they created enormous wealth, but at the cost of racial division and economic inequality that exceeded what we have here. They were in power democratically and then by corrupt dictatorship, as Fulgencio Batista210px-fulgencio_batista_president_of_cuba_1952 took power in a military coup before the 1952 election.
3. After the revolution, the economic and political systems were overturned. A new group took control of the systems and created greater equality of access, but at the cost of a far more brutal autocracy. Literacy rose to the highest level in the Western hemisphere, so that people could read the government publications (propaganda). Healthcare was expanded to be universal.
4. Although ideological management of the economy and the impact of the US boycott both contributed to the impoverishment of the population, those who remained had little incentive to trade one for the other. And, before all those effects were felt, they had zero incentive to permit the return of the Batista regime so the population never rose up in response to the Bay of Pigs invasion in 1961.
5. In the fall of 1975 I was living in France, and a leftist friend came up to me all excited to announce that Franco (dictator of Spain)

franco-1had died. I looked at her. “What are you so excited about? While we don’t know if he was happy, he had wealth and power and died in his bed at 83? What is there to celebrate?” I feel about the same way regarding Castro.
6. Obama’s opening to Cuba was fortuitous, coming at the precise right moment, before Fidel Castro’s death and his brother Raul’s eventual death as well.raul-castro His opening is a counterpoint to hardliners on the island who will want to continue the relationship of the past half century. Whether Obama’s successor will move forward or revert to earlier failed US policies remains to be seen.

Living on Spec

Posted by on May 29, 2015 Comments Off on Living on Spec

One of my children is an auditory learner in a world that honors visual learners, a person with kinetic intelligence in a world that honors academic intelligence. He told me that he wanted to know that getting training, where academics are a challenge, would get him a job.

It would be really nice if the world worked that way. I think everyone would prefer a world that worked that way. Unfortunately, it doesn’t, not at all. Instead of assurances of favorable outcomes, most of life is lived “on spec.” I explained to him that it is a business term that means doing something before you have an agreement on compensation. You need some research, so I do a research paper for you hoping you will pay me adequately. If you don’t, either I accept less than it is worth and insist on payment up front next time, or I simply write off the time I spent on it.

Artists are accustomed to working on spec. Rarely do they get a commission for a creative work, and that only after years of building a reputation. One warm summer evening in Nashville, I was standing outside the Bluebird Café for the evening program. I was by myself since I wanted to be sure to get in. A man approached across the parking lot and stood there with me. He was short and African-American. We talked. I asked if he wrote songs and if he played an instrument and if he had done any work I might know. He was non-committal and vague, giving me one word answers without being unfriendly. Eventually the doors opened, and he went in the back. Later that evening I learned that he was the evening’s attraction, Bobby Hebb, best known for Sunny.

He told the audience that night how many pairs of shoes he had worn out on the streets of New York trying to get a cut for the song, trying to get it recorded. Before he left that night, we had a good laugh together, largely at my expense. He was about the age I am now, and he died five years later. He believed in his song, his art. He believed that it should and would get recorded. However, he did not know—he wrote it on spec and wore out shoes selling it.

Hebb

Almost everything we do in life is on spec, not contracted for. We get an education, never knowing if it will lead to employment or anything more than a degree. Sometimes we end up hating the subject and changing to another major or switching to another career in graduate school. Even then, we are a nation of reinvented careers. I know an attorney who does data analytics, medical doctors with PhD’s as if they need both. My graduate training is in economics, something I did for 8 years, mostly using MS Excel. When I moved to a new city, I used down time at a printing plant temp job to teach myself MS Access, noticing a button that said “SQL.” My new found SQL skills got me a job in healthcare. I learned data mining and took an online course in SAS, and eventually I found myself in San Francisco working with SAS until I was laid off a year later, moving across the country to a firm that did not use SAS. Two years later they were acquired by a firm that used SAS, so once again I can use those skills. I learned all those skills on spec.

Doing things on spec is not limited to professional life. We join clubs and organizations on spec, either for professional networking or to build our social circles. I met the mother of my children speaking French at the Alliance Française. I met my current wife online. In the absence of foresight, we have no idea how the skills we develop today will work to our advantage tomorrow, whether speaking with someone who knows the language we just learned or electronically meeting someone on the other side of the world who is looking for the same things in life that we are.

Reading all of this, there is something in common, and there is no good word for it, so I will use the next-best word: faith. Now, I don’t mean faith in the sense of religious faith, as in believing in God to have eternal life. But, it is close to the religious faith that things work out for the best (I don’t believe that either.) What it means to me is that we do things on spec, and then we have faith that there will be some unknown and unpredictable return on our investment of time and effort.

Because we don’t know how that return may occur, the best we can do is find things that we get satisfaction in doing. I can’t say I enjoyed learning SAS. What I have tried to do in my life is become the best Sam I could be, put myself out there where other people had a chance of meeting me, and trust (have faith) that someone, whether a lover or an employer, would appreciate my efforts—all on spec.

Good guys and bad guys

Posted by on January 1, 2015 Comments Off on Good guys and bad guys

Nearly 30 years ago Robert Fulghum wrote a best-selling book entitled “All I Really Need to Know I Learned in Kindergarten.” While I did not read the book, much of the wit and wisdom became part of popular culture at the time. In a similar vein, when I was in elementary school, we learned about good guys and bad guys. In our recreation periods, we played games, taking the roles of one or the other, in Cops and Robbers, Cowboys and Indians, and Yankees and Rebels. Neither role was uniformly bad or good—it was a matter of perception—everyone took turns at both roles in the game. However, we did learn that there were good guys and bad guys in the world, and we learned that it was not always easy to tell which was which.

There is much in the last year to which that lesson applies. One example is the ongoing Syrian Civil War, which has victimized hundreds of thousands of civilians, who have been wounded, raped, and driven from their homes by the combatants. At the outset Syria was a majority Sunni Muslim country ruled by a brutal Shia Muslim (Alawite) dictator. The armed opposition was largely Sunni. Among them were some relatively secular Sunni elements as well as the Al-Nusra brigades (aligned with Al-Qaeda) and ISIS (broken off from Al Qaeda). All of these groups use captured weapons, many captured from recipients of US suppliers.

Here is an example where there are so many bad guys, it is hard to know where to help the good guys, if there are any. We tend to favor secular groups. It is unclear whether those groups are adequately trained and motivated against a minority regime fighting to stave off ethnic and political disaster as well as two religiously ideological groups opposing it. It is unclear if they would be as attractive to us in power. For a time we wisely stayed out of the conflict until ISIS began beheading people on YouTube. That got our attention, although it did not change the relative morality of any of the actors in the region. Indeed, our ally, the Saudi monarchy, routinely beheads dissidents, but prudently, not on YouTube. At the same time, the ISIS group is taking territory not only in Syria but in the Sunni regions of Shia Iraq, largely because the central government has not reached out to include the residents of those regions. As a result, we are once more wading into the morass created by our invasion nearly 12 years ago.

The US domestic headlines have been dominated by violent encounters between police and civilians, often with unarmed civilians being killed, many of them African-American. A large part of the population has chosen up sides, pro or anti-police, pro or anti-African-American. Unlike children, they rarely get to play for both sides. Because we did play for both sides as children, we learned the world was not as Manichean as we thought. Adults should be wiser, seeing even more shades of gray than children.

In the Middle East, none of the multiple sides is as good or as bad as we might like to think. In the US neither police nor civilians are as good or as bad as would like to think. To me the bad guys are the ones using guns to shoot at people, whether civilians shooting at police or police shooting at unarmed civilians. It is not the presence or absence of a uniform in an American city or on a foreign battlefield that tells who the good guys are.

So, my wish for 2015 is that overseas we pull back a bit, realizing our limits even to discern the good guys from the bad guys, much less do much about it. Indeed, sometimes we are the only good guys so we should put our efforts elsewhere. And, in the US I hope we will start holding the bad guys accountable, civilian or police. The rest of us, the good guys, police and civilians, deserve that.

Why I hope to live until I die

Posted by on September 28, 2014 Comments Off on Why I hope to live until I die

Seventy-five years is all I want to live. I want to celebrate my life while I am still in my prime. My daughters and dear friends will continue to try to convince me that I am wrong and can live a valuable life much longer. And I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible. That, after all, would mean still being creative after 75.

So wrote Ezekiel J. Emanuel, director of the Clinical Bioethics Department at the U.S. National Institutes of Health and head of the Department of Medical Ethics & Health Policy at the University of Pennsylvania, in the Atlantic magazine of September 17, 2014.

He argues that:

  1. He will have lived a complete life by then.
  2. Increased life expectancy has been accompanied by increased disease, accompanied by physical and mental disability.
  3. If we change our goals to match our ages, we still burden our children and alter their memories of us as decrepit rather than vibrant.
  4. “But 75 defines a clear point in time: for me, 2032. It removes the fuzziness of trying to live as long as possible.”

He concludes that certain medical tests and interventions that the larger population would consider quite normal should be ruled out after age 65, after age 70, after age 75.

It is a thoughtful and provocative essay that has attracted a lot of attention, presumably to the satisfaction of publisher and author. It could be that he wished to attract an audience, or it could be that as a bioethicist, he wished to begin a national conversation about end-of-life issues, rather than to be taken at face value. I would not question the sincerity of Dr. Emmanuel, nor would I question his education, which surpasses my own. I question his wisdom.

First, his choice of 75 is by his own admission arbitrary. Why not 74 or 76? Why not 79 or 81? Choosing an arbitrary age, or arbitrary criterion for anything, is a logical one-size-fits all or Procrustean standard. Such standards assume a homogeneity of population that does not exist, and Dr. Emmanuel presents counter-examples and outliers himself.

He further claims that a country that achieves life expectancy of 75 for both men and women need no longer concern itself with further life-lengthening efforts. This is a statistical fallacy. He does not state which life expectancy.

Our life expectancies change as we age. Much of the life expectancy quoted is at birth, including the risks of infant mortality. Life expectancy at age 18 is much different. Furthermore, life expectancy at age 70 is considerably higher, as there is a heightened risk of mortality in the fifties and sixties, with those reaching their seventies enjoying a much longer expectancy. On top of that, those are averages that say nothing about the experience of any one individual, and we live life as individuals not as averages, except for those rare individuals with precisely 2.4 children.

Second, when he points to the increase in disability and disease in extended old age, those figures apply to the general population, including the obese we see among us. They may not apply to those who climb Mt. Kilimanjaro in their fifties, as has Dr. Ezekiel.

Third, he is concerned about burdening his children, but he may prove to be a greater burden on his children by refusing available medical interventions than had he accepted them. A person with atrial fibrillation who has a pacemaker is less likely to experience a debilitating stroke than someone who refuses medical treatment. The only difference is that the stroke disability occurs in the person’s seventies rather than their eighties. That doesn’t sound the ethical high road to me.

Fourth, it is ironic that Dr. Ezekiel in pointing out the “spiritual and existential” reasons for his position to be rejected overlooks the religious drive behind his position: the desire for certainty in the face of life’s ambiguity. That drive motivates most religious belief in the same way that desiring to die at a fixed age “removes the fuzziness of trying to live as long as possible.”

Fifth, it could be that as a physician on record as opposing active euthanasia and recognizing that people do have disabilities that radically degrade their quality of life at an increasing rate with age; he is left with the only alternative being a form of very passive self-euthanasia, which he describes in other terms in the essay.

Now, the essay is replete with disclaimers that Dr. Ezekiel is not trying to convince us nor does he think it unethical to conclude otherwise and so forth. In short, he is restricting his conclusion to a population of one that we cannot know as well as he does. If that were truly so, the essay need not be published anywhere but a diary. So, I find the disclaimers to be disingenuous.

At the outset, I challenged Dr. Ezekiel’s wisdom but not his sincerity. I did so on two grounds.

First, in academic research, with which any physician is familiar, it is a cardinal rule to state what you know, what you don’t know, and what should be the next steps. My impression is that Dr. Ezekiel confuses what he knows with what he doesn’t know. Among the things he doesn’t know, not because he is not intelligent and knowledgeable, but because he is not omniscient are:

  1. What the outcomes of two personal time lines would be, one being the refusal of interventions and the other being the acceptance of interventions.
  2. What medical advances will occur in the next fifteen years to address some of his concerns about disability accompanying expanded life expectancy.

Have we not all wondered at some time, what if we had married person A instead of person B, what if we had taken job A rather than job B, visited country A rather than country B, and an almost infinite number of similar questions that are summarized in Robert Frost’s The Road Not Taken? And the power of the poem lies in our understanding that we simply cannot see the path that disappears in the underbrush, nor can Dr. Ezekiel.

In the field of economics, everyone becomes familiar with work of Thomas Malthus, who predicted widespread war and famine accompanying population growth. It may still happen, but it has not happened yet because Malthus was unable to take into account the impact of technological advance. The same technological advance that has helped us lengthen our lives by declining infant mortality and more hopeful outcomes to heart disease and cancer may yet address the disabilities accompanying aging. What I know is that at my age (67) I can walk 5 miles easily and 10 miles less easily whereas my parents’ generation could not at my age. I carry two stents in my heart, which have no lengthened my life but improved its quality such that I can climb a hill without feeling faint. Such qualitative improvements from technology should not be overlooked.

Second, the ancient Greeks had a word that survives in our studies of their literature and ours, hubris, an excessive pride or self-confidence. And, to me that is the lack of wisdom in an otherwise well-written, thoughtful essay. We have come a long way as a species. With luck and wisdom that we do not always demonstrate, we will have a long way to go. Part of that wisdom is a certain humility that I found lacking in the essay. Even about ourselves we know less than we pretend to know. A person contemplating his death at 75 does not know he will not be hit by a car at 60 or suffer a heart attack or learn he has pancreatic cancer. By the same token, there are imponderables on the other side of 75 as well, good and bad, desired and feared. A person cannot plan that way, but the humility of admitting those possibilities should come through in this essay.

Many years ago I lived in the backyard converted garage of an older couple in Miami, Florida. They had an old dog. One day, the man about 70 years old was musing about how the dog was arthritic, had trouble walking and could not climb up on his lap, and how perhaps it was time to put him down. It gives me pause and a needed dose of humility in thinking about such things to recall that the dog outlived the man.

Looking Backward

Posted by on May 25, 2014 Comments Off on Looking Backward

If you mention to a friend or colleague that you have an upcoming reunion, their first reaction is likely to be “You should go.” For many people that would be sound advice, even if the adviser cannot articulate precisely why.

Most of us did not escape high school or college free of demons. As the cult classic The Breakfast Club makes clear, no matter what role one played in high school, there were demons accompanying it.

My 50th high school reunion was 10 days ago. I did not attend.

The decision not to attend was made in part 30 years ago. I attended both my 10th and 20th reunions.

At my 10th reunion I was struck by two observations. First, some people looked like they were attending their 20th reunion. Second, some people, including my friends from high school, were having almost the exact same conversations they were having ten years earlier.

At my 20th reunion my now ex-wife and I were the first ones to get up and dance. I had not attended any high school dances. I had scrambled to find a date for the prom. It was good to put down that particular demon.Looking Back

Having a convinced a childhood friend to attend these reunions, I found that he became a born-again reunion attendee. He wanted me to join him for the 25th and 30th. I no longer saw the point.

Finally, I assured him that if we were both in good health, we would attend the 50th together. I figured that one of us would be dead by then, releasing me from the promise, one way or another.

That did not happen, so as the years and months approached the reunion date, I resigned myself to attending. However, as luck would have it, my friend’s daughter graduated college the same weekend, releasing me from my promise. The moral seems to be that promises should be made as far in advance as possible, increasing the possibility that something unforeseen will intervene to release you from your vow.

My 50th was to be in another city from the one where I grew up and went to school, for reasons that escaped me. The cost of admission was $119 per person, leaving me the alternatives of a considerable investment to have my wife accompany me or to attend alone for more money than it was likely to be worth to me.

But that is not the reason I did not attend.

In past times reunions served a purpose of reconnecting individuals with their pasts. In addition, it was possible to reconnect with people who had fallen away as life progressed, sometimes simply because a letter did not catch up or a phone number had changed.

That is no longer the case. Most people can be reached by Google or Facebook searches. If not, it is unlikely that a reunion committee will have contact information.

The obvious conclusion is that when people do not stay in touch, there is a reason they have chosen not to do so. They may not even be aware of the reason, but it is there nonetheless.

We grow. We change–sometimes at highly different speeds.

We continue on our journeys, and the people we once knew at a very particular time of life, the people whom we saw every day, the people who were central to our lives outside our homes, are simply no longer relevant.

As we continue on our journeys, there is nothing wrong with the indulgence of a brief glance in the rear-view mirror, but the road is ahead of us not behind us.

My journey continues. My eyes are on the road ahead. And what is behind me is simply a bit of dust stirred up on the road in the wake of my forward movement.

Congratulations, America!!

Posted by on April 30, 2014 Comments Off on Congratulations, America!!

Is there a more self-congratulatory nation than the United States? When it comes to self-congratulations, we’re number one.

If there is true American exceptionalism, it is, among other things, that we are exceptionally congratulatory of ourselves.

Perhaps the most well-known example was the large “Mission Accomplished” banner behind President George W. Bush on the aircraft carrier USS Lincoln on May 1, 2003 as he said, “In the Battle of Iraq, the United States and our allies have prevailed.”mission accomplishedLarry Downing/Reuters

More recently we have the twin cases of Cliven Bundy and Donald Sterling to make us feel good about ourselves.

The past two weeks have been Bundy’s 15 minutes of fame. Here is someone who thinks refusing to pay grazing fees for his cattle herd to the government is taking the high moral ground, as opposed to those on welfare who fail to report some outside income they earned.

And, when the government comes calling, he gets a few of his friends with weapons together, forcing the federal employees to either risk a blood bath a la Waco or retreat, to the applause of Fox News and others on the Right.

Among the gems from Mr. Bundy was denouncing the legitimacy of the US Government while standing in front of an American flag. No single mother on welfare could have shown more ignorance than Mr. Bundy and his supporters, and almost none of them would have shown his arrogance.Cliven Bundy

Then, to universal surprise, we learned that he was as ignorant about the history of this country, particularly with regard to race, as he was about the government and his obligations as a citizen. So the political Right and Left were shocked, shocked to learn of his racism. They joined hands to universally condemn him while patting each other on the back at having taken the moral high ground. Mission accomplished!

For someone with an entirely different background and lifestyle, Donald Sterling’s saga played out in a parallel manner. Sterling is a billionaire owner of multiple real estate holdings and assets including the Los Angeles Clippers NBA franchise. He was born in 1934 and came of age long before the Civil Rights struggle. His attitudes on race seem to have been unchanged by the 1960’s.

He seems to believe that people should stay with their own kind for the most part, so he wanted only Koreans renting from his properties in LA’s Koreatown, and wanted Latinos and African-Americans in their own areas. The fact that he had a multi-racial girlfriend did not seem to alter those views. Nonetheless he received an NAACP lifetime achievement award.

As a result of a convoluted controversy and lawsuit involving his wife and his mistress, a tape of him making remarks that he probably made fairly often was released, and people from the President of the United States down seemed to be in line to condemn them. The NBA decided to ban him from life from NBA games and move to take the franchise away. UCLA refused a $3 million dollar gift. Mission Accomplished!!

Despite different backgrounds and occupations, Bundy and Sterling share a fundamental ignorance about the values of this country in general and about race relations in particular. However, does anyone seriously think that none of the other NBA owners are racists? Does anyone seriously think that banning all racists from NBA games wouldn’t leave a few empty seats–they may be quieter, but do we doubt they are there? And, does anyone really think that if he had been more successful with the Clippers, bringing in money for the NBA, that they would be so quick to ostracize him?

We really like congratulating ourselves about Bundy and Sterling because it distracts us from the Supreme Court gutting the Voter Rights Act and Affirmative Action plans, on the grounds that times have changed racially, Bundy and Sterling notwithstanding. It is certainly cheaper than raising taxes to pay for opportunities for the poor of all races to eat (SNAP program cuts) or to go to school (Pell Grants) or to provide health care to the working poor by expanding Medicaid. Instead, we let billionaires put the thumb on the scales of our elections and give them tax subsidies to do so, eliminate estate taxes that might require their progeny to work for a living, decertify the unions that might give working people some leverage against the wealthy, and then congratulate ourselves about our support of liberty.

Well, pardon me if I don’t get too excited about the shoot-in-the-barrel, easy target, bullying of two ignorant old racists as I’m afraid of getting slapped upside the head by all the back patting. USA! USA!

When can we smile at tragedy?

Posted by on April 5, 2014 Comments Off on When can we smile at tragedy?

Last week two online events occurred that stimulated this question.

First, a train jumped the track in Chicago. There were no serious injuries; anyone taken to the hospital during morning rush hour was released by noon. The event yielded the following photo:

Chicago_train_20140326

Seeing a train on an escalator, particularly when it could have taken the steps, provoked a smart ass comment from me on a friend’s Facebook posting. Another friend of hers took umbrage, saying that I should not make light of it and that I would not feel that way if I had been related to a victim.

Later that day I was on Quora.com. Someone had posted a reference to being sexually assaulted 20 years earlier. Another Quoran posted a light remark, while a third objected to making light of an assault.

These two incidents made me think: when is it appropriate to make light of tragedy, and when is it completely tacky, and, more importantly, what is the distinction between the two?

The first criterion that occurred to me was magnitude. I have only heard one joke about the Nazi Holocaust or Shoah, and I only heard it once, as an undergraduate. The size and nature of the suffering puts it beyond humor. [Digression for the joke: an old Jewish man was sitting beside the road watching the Nazis parade by during the early 1930s. He was smiling. Hitler approached and asked what he was smiling about. He replied, “When Haman tried to eliminate the Jews, we got hamentashen (pastries) and when Antiochus oppressed us, we got latkes (potato pancakes). I am wondering what kind of food we will have to commemorate your defeat.”]

However, it cannot simply be a matter of magnitude. World War II deaths as a whole were in the tens of millions, compared to the 6 million deaths attributed to the Shoah. Indeed, there were more Chinese deaths than Jewish deaths in World War II.

It might be that magnitude plus severity is a better measure. If we measure severity as a percentage of the population killed, then the percentage of the population in Lithuania, Latvia, and Poland are above 10 percent, a high level of intensity, and many of these were Jewish victims of crimes against humanity. In addition, the percentage of the Jewish population subjected to genocidal killing was much higher.

Besides the question of magnitude and severity, the question of proximity in time is pertinent. Arguably the Black Death of the 13th and 14th centuries had as profound an impact, but given that the events occurred 700 years ago, Monty Python was not criticized for making light of the plague in Monty Python and the Holy Grail. Similarly, Monty Python has done skits on the Spanish Inquisition, whose excesses are a matter of historical record. Similarly, we have heard, or can imagine hearing, someone say, “Aside from that, how was the play, Mrs. Lincoln?” We cannot imagine someone saying, “Aside from that, how was the visit to Dallas, Mrs. Kennedy?” The difference is 100 years. None of us will be there to see if the second one becomes acceptable, but even 50 years after the event, it is still too raw for humor.

In addition to proximity in time, the proximity to the event of you and the audience make a difference: if the victim of the tragedy is in your audience, humor is unlikely to be appropriate, whether the audience is live or virtual.

Considering the number of variables involved, it is not difficult to overstep a boundary, especially when the humor police are watching. Someone with a comic bent has two choices: either keep humor private, or accept the likelihood that, even considering all the angles and possibilities of sensitivity, someone will criticize.

Addiction: Twenty-first Century Style

Posted by on November 19, 2013 Comments Off on Addiction: Twenty-first Century Style

Technology is wonderful, ever moving forward. Now that cigarettes and other tobacco products have been thoroughly discredited as nothing more than a dirty 20th Century addiction, the purveyors of nicotine addiction have developed the e-cigarette for the 21st.

None of that harmful tar. None of that distasteful, annoying smoke. Just pure pleasure, as innocent as sucking a straw.

The Food and Drug Administration (FDA) is not convinced and is expected to issue regulations shortly.

E-cigarettes are a battery-powered device, about the size of a cigarette, that heats a nicotine-laced liquid into a vapor to be inhaled.

First, the FDA will not be able to regulate e-cigarettes as medical devices. That was decided by the DC Court of Appeals in Sottera, Inc v. FDA at the end of 2010. That means that restrictions will be similar to tobacco products rather than to nicotine patches.

Second, there will be considerable debate about the relative safety of e-cigarettes. While it is true that the tar and smoke is missing, it is unclear what the effects of the vapor components are both or the “vaper” and those around him.

A 2012 study at the University of Perugia (Italy) concluded:

The e-cigarette seems to give some advantages when used instead of the conventional cigarette, but studies are still scanty: it could help smokers to cope with some of the rituals associated with smoking gestures and to reduce or eliminate tobacco consumption avoiding passive smoking. However, the e-cigarette causes exposure to different chemicals compared with conventional cigarettes and thus there is a need for risk evaluation for both e-cigarettes and passive steam exposure in smokers and non smokers.

In August, 2013 respected researcher Igor Burstyn of the Drexel University School of Public Health issued a study financed by The Consumer Advocates for Smoke-free Alternatives Association (CASAA), an advocacy organization of the e-cigarette industry. Burstyn’s work and presentation is rigorous, but it is a technical study, not the peer-reviewed journal article considered the gold standard among researchers. While finding that the contaminants are generally safe, Burstyn:

  1. does not evaluate the risk of nicotine exposure to the person “vaping.”
  2. notes the difference in standards between exposure to a willing user and more stringent standards for an unwilling bystander.

Burstyn report

This approach to secondhand vapors provides a legal and philosophical foundation for applying existing tobacco regulation to the newer nicotine delivery systems.

Third, the e-cigarette industry is following the lead of the tobacco industry in its advertising. Note the remarkable parallels in Cigarette Flashbacks, a presentation by three Democratic members of the House Energy and Commerce Committee.

Fourth, there is widespread concern about the marketing and increased consumption of e-cigarettes by teenagers. Ninety percent of adult smokers had begun smoking in their teen years. The issue is well summarized by Health.Howstuffworks.com Flavoring the vapor with chocolate, caramel, strawberry, and bubble gum suggests a conscious attempt to lure youth into early addiction for later profits. Similar concerns have been expressed about the flavorings in hookah smoking as well. The Centers for Disease Control and Prevention recently issued a report on the percentages of teenagers using flavored tobacco products, nearly half of the consumption is flavored.

In the Jewish tradition, consumption of dairy and meat products together is forbidden. Technically, it would be permitted to have soy cheese on a hamburger, but the rabbis have forbidden that as well, because the appearance of violation by believers might encourage others to violate the prohibition.

It is clear that the appearance of smoking cigarettes should be treated no differently than the consumption of cigarettes. The difference between suggesting “Reach for a Lucky instead of a sweet,” and “E-cigarettes have no tar or smoke,” is minimal.

The FDA should treat e-cigarettes as tobacco products, and the several states should follow the examples of Utah, North Dakota, New Jersey, Arkansas, and the District of Columbia in banning indoor use in public places. Additionally, sales to minors should be banned as well as Internet sales since age-verification is not possible on line. In short, we need to bring these products under the same regulations as their tobacco cousins–NOW.

Getting your teeth into health care

Posted by on October 27, 2013 Comments Off on Getting your teeth into health care

We all know the reasons for going to the dentist regularly:

  1. Early detection (cavities, gum disease, oral cancer, bruxism)
  2. Checking existing fillings for structural weakness or peripheral decay
  3. Review of oral health practices

These are dental reasons, but there are other reasons as well.

The relationship between dental health and other medical health is not a new concept, with studies going back to the 1980’s. For example, the statistical relationship between heart attacks and poor dental health was noted in a 1989 Finnish study.

Managed care organizations have a strong financial incentive to lower health care costs. Healthier members have lower medical costs, so improving the health of members is an attractive alternative to cutting benefits in order to lower costs.

Aetna has been a leader in “Dental-Medical Integration” (DMI) as an approach to that end.

A study in 2006 found significant relationships between treatment for gum disease ( a proxy for having gum disease) and higher medical costs for cardiovascular, cerebrovascular, and diabetic conditions, heart, stroke, and diabetes, respectively.

In 2009, Aetna reported considerable success in getting dental care for at risk members:

In 2008, nearly 67,000 medically at-risk members sought dental care after being enrolled in Aetna’s Dental Medical Integration program. At-risk members are identified as those with diabetes, heart disease and pregnant women who have not seen a dentist in 12 months or more.

A 2011 University of Pennsylvania study in collaboration with Cigna Dental established lower medical costs two years after periodontal (gum) treatment:

2011_UPa_Dental

Earlier this month Aetna reported:

  • Lowered their medical claim costs by an average of 17 percent
  • Improved diabetes control by 45 percent
  • Used 42 percent less major and basic dental services
  • Required 3.5 percent fewer hospital admissions year-over-year compared to a 5.4 percent increase for non-members

With the caveat that the Aetna programmed targeted individuals with particular diagnoses who had not seen a dentist in a year, we are nonetheless facing an important question:

Is it time to end the division between dental and medical insurance, treating health care for the mouth as a medical specialty like others, and dentists as medical specialists like others?

Competition, Cooperation, and Health Care

Posted by on October 14, 2013 Comments Off on Competition, Cooperation, and Health Care

Maybe it’s the days of endless government shutdown. Maybe it’s the days of endless rain.

Writing about any of it comes hard to me. I am uncharacteristically quiet and reflective.

We live in a society built on competition. The economic system creates wealth and rations scarce resources through competition. Democracy is a competition for the support of voters. And, no society is more sports-minded than we are, with giant arenas and stadiums for a variety of sports, each with millions of followers.

However, all of this competition occurs in the context of a society. A society implies certain shared values, a modicum of cooperation, and concern for other members of the society, if not for their own sakes, then for the sake of the society.

Consequently, a competitive society is one with built-in contradictions. At the extreme, economic competition results in great wealth, poorly distributed, and concentrated in the hands of the few. At the extreme, political competition, like sports competition, requires that victory trumps all ethical considerations, including the needs of the society or sport.

On the other extreme, a completely cooperative society, devoid of competition, sharing things equally, is unlikely to thrive. As our conservative friends point out, the incentives for wealth creation and technological progress based on expenditure are likely to be lacking. In addition, there will be free riders, people who wish to partake without producing.

The political and social pendulum in the United States often swings between competition and cooperation, between liberty and equality. At this point in time, it seems to me that we have swung a bit too far toward competition. We have a Congress that cares more about the next election and scoring political points than public policy; we have a Speaker, who should know better, but is more concerned about the challenge to his leadership than the American economy.

Behind it all are two ideologies that seem singularly unconcerned about any impact, other than how a position is measured against the yardstick of a belief system, a non-religious libertarianism allied with a particularly narrow version of Christianity, aligned together in opposition to government initiatives, despite their obvious contradictions. It is a characteristic of ideology and utopia, as Karl Mannheim called the narrow beliefs of the present and the future, that purity of belief surpasses any human need.
ideology and utopia

Combining these strong ideological commitments with the political system results in the political impasse we are experiencing. Closed belief systems can rationalize economic collapse as a necessary, ultimate good, so compromise is not only unnecessary from that perspective, but traitorous. As Eric Hoffer put it,

It is the true believer’s ability to “shut his eyes and stop his ears” to facts that do not deserve to be either seen or heard which is the source of his unequaled fortitude and constancy. He cannot be frightened by danger nor disheartened by obstacle nor baffled by contradictions because he denies their existence

So, the campaign against the program of our current President can pivot from health care to spending to entitlements, but is consistently against the President and his positions. When the economic consequences of the shutdown and the debt limit crisis are tallied, they will say, “See, we told you that the Affordable Care Act would destroy the economy.”

Politicians of all wings, parties and beliefs routinely employ spin–stretching the truth to make their points; however, at some point the distance from the truth is sufficient to call “spin” an outright falsehood. An example, in health care, was the charge that Obamacare mandated “death panels.” (Physicians routinely discuss end-of-life issues with their patients. The proposal was that they be reimbursed for the time so spent.)

As Mark Twain put it, “A lie can travel half way around the world while the truth is putting on its shoes.”

When confronted with an obvious falsehood or exaggeration, the honest person faces a dilemma: does the speaker/writer truly believe what is written, or is that person cynically exploiting the ignorance of others?

Here are some of the arguments about the Affordable Care Act that have been dragged into debate about fiscal policy, the Federal budget, and the US statutory debt limit.

  1. Congress has exempted itself from Obamacare.
    The fact is that Congressional employees will be shopping for health care on the exchanges rather than receiving employer-provided health care as would most businesses with a comparable number of employees. As employees, they will receive an employer contribution that reduces the monthly premium cost.
  2. Large enterprises have been made exempt from the mandate to provide coverage so individuals should be exempt as well.
    Large enterprises are still required to provide health insurance coverage for their employees as scheduled; however the Justice Department will not be imposing penalties immediately. Furthermore, the individual mandate is an entirely separate issue–it is the linchpin of eliminating denial of coverage for pre-existing conditions. Without it, no one would buy health insurance until they needed it, with the assurance that their health condition could not be denied.
  3. Health insurance premiums are going up because of Obamacare.
    With the exception of the past 3 years, health insurance premiums have been rising by double digit percentages each year. The rise slowed because of the deep recession we are emerging from. Health insurance premiums will continue to rise, largely driven by technology (MRIs are expensive), now that the recession is almost over. Furthermore, premiums may seem very high to individuals who have not been able to or been interested in purchasing insurance until now. Health insurance is expensive.
  4. Companies are letting full-time workers go and hiring part-time workers in their place.
    1. Many individuals choose part-time employment over full-time employment. So, the only concern should be involuntary part-time employment rather than all part-timers.
    2. There has generally been a rise in part-time employment during economic recessions. The recent recession is no different.
    3. Many new jobs are coming into the economy to help with Obamacare, as well as new hires in the private sector to meet the needs of the health care law mandates for preventive care and individual coverage.

      4. [It should be noted that individuals concerned about employment issues would never close the Federal government or permit it to be closed, since the loss of spending by Federal workers ripples through the labor market as business owners determine whether to take on new hires, and the lack of Federal issuance of permits in several areas e.g. a Vermont micro-brewery, adversely impacts employment.]

    And as I was reflecting upon the original conundrum, how to reconcile cooperation and competition, liberty and equality, while retaining the best of both, I came across a quotation from Milan Kundera,

    kundera

    “Too much faith is the worst ally. When you believe in something literally, through your faith you’ll turn it into something absurd. One who is a genuine adherent, if you like, of some political outlook, never takes its sophistries seriously, but only its practical aims, which are concealed beneath these sophistries. Political rhetoric and sophistries do not exist, after all, in order that they be believed; rather, they have to serve as a common and agreed upon alibi. Foolish people who take them in earnest sooner or later discover inconsistencies in them, begin to protest, and finish finally and infamously as heretics and apostates. No, too much faith never brings anything good…”

    The Roman playwright Terence wrote “Ne quid nimis,” alternatively translated as “Nothing in excess,” or “All things in moderation.”
    Terence

    Moderation isn’t sexy or attractive. It doesn’t cause the adrenaline rush of ideological combat. But, I think it is the medicine we need now.

    Moderation in politics, moderation in spending, moderation in punditry. Here’s to moderation!!